The osteonecrosis or aseptic necrosis consists of a bone infarct. It is more common in the epiphysis since they have worse blood supply. It is often due to chronic treatment with corticosteroids (in rheumatic diseases or oncology). The most common sites are the hip, the femoral condyles and astragalus (Fig. 9A-B).

The vascularized fibula is an ideal technique for the treatment of osteonecrosis of the femoral head to avoid progression of the collapse of the head, osteoarthritis of the hip and eventual hip replacement. The vascularized fibula allows blood supply arrival to the femoral head, thus revascularizing and revitalizing it. Nuclear medicine studies by Dr Soldier demonstrate this phenomenon (Fig. 9 C-D). With this treatment, we can avoid hip replacement surgery at an early age.

Figure 9A. The radiograph shows an altered signal in the left femoral head, and an initial collapse. This 15-year-old patient takes corticosteroids as a treatment for a rheumatoid problem.

Figure 9B. The MRI shows the area of necrosis of the femoral head. If left untreated, the head will continue to further deform itself, and an early osteoarthritis will eventually appear, requiring hip arthroplasty.

Figure 9C. Vascularized fibular graft prior to implantation. The required length is being adjusted and we are also taking advantage of the periosteum to increase the supply of mesenchymal stem cells.

Figure 9D. Radiograph showing placement of the vascularized fibular graft in the femoral head, through a cervical tunnel to bring blood flow to the area where there was initially osteonecrosis, now occupied by iliac crest graft.

Figure 9E. The SPECT-CT scan shows high activity in the femoral head. This means a great vascularization of the femoral head, due to successful treatment with a vascularized fibula.

Furthermore, Dr Soldado described the use of vascularized periosteum in diseases of the foot and wrist, obtaining good results in the revascularization of osteonecrosis of the astragalus and scaphoid (Preiser disease) (Fig. 10).

Figure 10A. MRI showing a necrotic area within the body of the talus. The 14-year-old patient takes corticosteroids for a rheumatic disease. To revascularize the necrosis area, Dr Soldado implanted a vascularized periosteal flap from the first metatarsal.

Figure 10B. These images show the successful outcome of the technique. The talus has not collapsed and the movement of the ankle has been recovered. SPECT-CT demonstrate revascularization of the talus.